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Appendix 1 - Example of Chart Abstraction
ICR 201707-0920-004 · OMB 0920-1011 · Object 75226101.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Appendix 1 - Example of Chart Abstraction |
| Author | Centers for Disease Control & Prevention |
| Last Modified By | Writer |
| File Modified | 2013-11-14 |
| File Created | 2026-10-30 |
| Conversion State | complete |
Extracted Text
Appendix 1. Chart Abstraction Form
Form Approved
CDC ID:_____
OMB No. 0920-XXXX
Exp. Date XX/XX/XXXX
Patient Name: ________________________________________________________
CDC ID#:____________________________________________________________
Hospital #1: _________________________________________________________
MRN#: ___________________________________________________
Hospital #2 (if transferred): _____________________________________________
MRN#: ___________________________________________________
Street Address: _______________________________________________________
City: ________________________ State: _______ Zip: ____________
Country:_________________
Telephone number: ______________________
Alt Telephone number:______________________
Public reporting burden of this collection of information is estimated to average XX minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)
Name of person completing form:_______________________________________________
Demographic Information
Age: ________ DOB___ __/ __ __ / __ __ __ __
Sex: Male Female
What is your race? (Check all that apply.): American Indian or Alaska Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White
Are you Hispanic or Latino?: Yes No
Work (describe):
Timeline and Outcome
Date of prodrome (includes GI symptom) onset: ____/____/_________
No prodrome
Date of neuro illness onset: ____/____/_________
Date of first hospital admission: ____/____/_________
Initial or admitting diagnosis:
Outcome of illness: Died (Date (dd/mmm/yyyy):_________________)
Discharged to chronic care or rehabilitation facility
Discharged to home (Date:_________________)
Still hospitalized
(Date:_________________)
Prodrome Illness Symptoms
Diarrhea Yes No Unk Vomiting Yes No Unk
Fever Yes No Unk Cough Yes No Unk
Sore Throat Yes No Unk Joint pains/aches Yes No Unk
Bloody stool Yes No Unk Rash Yes No Unk Headache Yes No Unk Abdominal Pain Yes No Unk
Other__________________________
Duration of prodromal symptoms: ___________ days
Location of patient in 7 days before prodromal symptoms:
Past Medical and Neurological History
Past Medical and Neurological History (include EtOH, tobacco, drug use):
Exposure History
Travel History (include all places visited in prior 30 days—include dates of travel):
Describe any agricultural or pesticide exposure in past 6 weeks:
Any upper respiratory infection in the last 6 weeks? Yes No Unk
If yes,
What date of onset?: ____/____/_________
Any gastrointestinal infection in the last 6 weeks? Yes No Unk
If yes,
What date of onset?: ____/____/_________
Any vaccinations received in the last 6 weeks? Yes No Unk
If yes, date of receipt: __ / __/ _____
If yes, vaccine(s)_administered________________________________
Ill household contacts in the past 6 weeks? Yes No Unk
If yes,
Nature of illness: _____________________________________________________
Toxic/Chemical Exposures
1. Did patient recall taking any herbal or folk remedies during 2 weeks prior to illness onset?
Yes
No
Unknown
If YES,
Remedy 1: __________________________________
Remedy 2: __________________________________
3. Did patient recall eating any wild picked plants (like. buckthorn or Karwinskia Humboldt pictured below) during 2 weeksprior to illness onset?
Yes
No
Unknown
If YES,
Plant 1: __________________________________
Plant 2: __________________________________
Neuro Symptoms
Initial neurological signs and symptoms (describe):
Onset of weakness within first week of neuro illness?
Yes
No
Unknown
Concurrent symptoms:
Fever
Headache
Meningismus (nuchal rigidity, photo/phonophobia)
Altered mental status
Nausea/vomiting
Muscle pain/myalgia
Other
Specify if other: __________________________________________________________________________________________
Distribution of weakness at maximal weakness
Symmetric
Asymmetric
Unknown
Check all that apply:
Right UE
Left UE
Right LE
Left LE
Prox
Dist
Prox
Dist
Prox
Dist
Prox
Dist
Neck Flexors/Extens.
Respiratory muscles
Quadriplegia/whole body paralysis
Facial muscles
Describe weakness distribution at maximum: ___________________________________________________________________
Approximate date of maximal weakness: ____/____/_______________
Reflexes in affected body parts at time of maximal weakness:
Areflexic
Hyporeflexic
Reflexes normal
Hyperreflexic/spastic
Reflexes not tested
Unknown
Tone in affected body parts at time of maximal weakness:
Flaccid
Hypotonic
Tone normal
Hypertonic/spastic
Tone not tested
Unknown
Sensory abnormalities present?
Yes
No
Unknown
Date of sensory symptom onset: _____/_____/____________
Description of sensory abnormalities: __________________________________________________________________________
type _____________________________________
Pain present?
Yes
No
Unknown
Date of pain onset: ____/____/_________________
Description/location of pain: _________________________________________________________________________
Prominent dyspnea/shortness of breath present?
Yes
No
Unknown
Approximate date of dyspnnea onset: ____/____/__________
Patient ever intubated?
Yes
No
Unknown
If yes, date of intubation:
Date of extubation:
Tracheostomy required?
Yes
No
Unknown
Bowel/Bladder involvement present?
Yes
No
Unknown
Description of bowel/bladder involvement: _______________________________________________________________
Date of bowel/bladder involvement: ____/____/__________________
Neurodiagnostics: Please indicate whether the following tests were performed. Record all results on accompanying worksheet.
1. Head computed tomography
2. Spinal computed tomography
3. Brain magnetic resonance imaging
4. Spinal magnetic resonance imaging
5. Electromyography/nerve conduction studies
6. Pulmonary fluoroscopic studies
Please indicate whether any of the following treatments or procedures were rendered during the course of illness:
1. Intravenous Immune Globulin (IVIG)
Date started: ____/____/_____
Date stopped: ____/____/_______
2. Plasmapheresis/plasma exchange
Date started: ____/____/_____
Date stopped: ____/____/_______
3. Alpha-interferon
Date started: ____/____/_____
Date stopped: ____/____/_______
4. Corticosteroids
Date started: ____/____/_____
Date stopped: ____/____/_______
If yes, dosage used: __________________________________________________________________
5. Other immunomodulating agent (Imuran, etc.)
Date started: ____/____/_____
Date stopped: ____/____/_______
If yes, specify: _________________________________________________
7. Muscle biopsy
If yes, date obtained: ____/____/______________
If yes, specify site of biopsy: _______________________________________________________________________
If yes, narrative of result: ________________________________________________________________________________________
_______________________________________________________________________________________________________________
Lab results: Culture results
If any bacterial, viral or fungal culture results were obtained, please note the following results
Culture type
Result
Specimen type*
Date
(Check one)
(Check one)
If positive:
Bacterial
Viral
Fungal
No growth
Positive
Organism 1
Organism 2
Organism 3
*Specimen type: Blood, bronchoalveolar lavage (BAL), cerebrospinal fluid (CSF), nasopharyngeal swab/aspirate, pericardial fluid, peritoneal fluid, pleural fluid, sputum, synovial fluid, tissue (specify site), throat/oropharyngeal swab, stool or urine
Diagnostic Tests for Other Infectious Diseases (include Antibody tests/serology, antigen detection, PCR and special stains)
Specimen type*
Date
Test performed
Results
Interpretation
Laboratory
*Specimen type: Blood, bronchoalveolar lavage (BAL), cerebrospinal fluid (CSF), nasopharyngeal swab/aspirate, pericardial fluid, peritoneal fluid, pleural fluid, acute serum, convalescent serum, paired sera, sputum, synovial fluid, tissue (specify site), throat/oropharyngeal swab, stool or urine
Please attach results of all neurodiagnostics (include detailed EMG results if available):
FINAL BRIGHTON CASE DEFINITION CLASSIFICATION: (See Appendix
Guillain-Barre Syndrome
• Level I
• Level 2
• Level 3
• Level 4
• Level 5
Fisher Syndrome:
• Level I
• Level 2
• Level 3
• Level 4
• Level 5
APPENDIX I: BRIGHTON CASE DEFINITION CRITERIA
Guillain-Barré Syndrome
Level I (requires ALL criteria)
1. Bilateral AND flaccid weakness of the limbs
2. Decreased or absent deep tendon reflexes in weak limbs
3. Monophasic illness pattern AND interval between onset and nadir of illness between 12 hours and 28 days AND subsequent clinical plateau
4. Electrophysiologic findings consistent with GBS
5. Cytoalbuminologic dissociation (i.e., elevation of CSF protein level above laboratory normal value AND CSF total white cell count <50 cells / mm3
6. Absence of an identified alternative diagnosis for weakness
Level 2
1. Criteria 1, 2, and 3 for Level 1 fulfilled
AND
2. CSF total white cell count <50 cells/mm3 (with or without CSF protein elevation above laboratory normal value)
OR
If CSF not collected or results not available, electrophysiologic studies consistent with GBS
3. Absence of identified alternative diagnosis for weakness
Level 3
1. Criteria 1, 2, and 3 for Level 1 fulfilled
2. Absence of identified alternative diagnosis for weakness
Level 4
1. Reported event of GBS, with insufficient evidence to meet case definition
Level 5
1. Not a case of GBS
Fisher Syndrome
Level 1 (Requires ALL Criteria)
1. Bilateral ophthalmoparesis AND bilateral reduced or absent tendon reflexes, AND ataxia
2. Absence of limb weakness
3. Monophasic illness pattern AND interval between onset and nadir of weakness between 12 hours and 28 days AND subsequent clinical plateau
4. Cytoalbuminologic dissociation (i.e., elevation of cerebrospinal protein above the laboratory normal AND total CSF white cell count <50 cells/mm3)
5. Nerve conduction studies are normal, OR indicate involvement of sensory nerves only
6. No alteration in consciousness or corticospinal tract signs
7. Absence of an identified alternative diagnosis
Level 2
1. Criteria 1, 2, and 3 for Level 1 fulfilled
AND
2. Cerebrospinal fluid (CSF) with a total white cell count <50 cells/mm3 (with or without CSF protein elevation above laboratory normal value)
OR
Nerve conduction studies are normal, OR indicate involvement of sensory nerves only
3. No alteration in consciousness or corticospinal tract signs
4. Absence of an identified alternative diagnosis
Level 3
1. Criteria 1, 2, 3, 6, and 7 for Level 1 fulfilled
Levels 4 and 5 as for GBS